Objective To analyze the clinical effect of TINAVI robotic system-assisted pedicle screw internal fixation for thoracolumbar fracture with a Thoracolumbar Injury Classification and Severity Score (TLICS) of 4. Methods A total of 38 patients with TLICS 4 thoracolumbar fracture treated between January 2019 and January 2021 who met the selection criteria of Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital were retrospectively analyzed. According to the results of doctor-patient communication, 18 cases were treated with robot-assisted minimally invasive surgery (robot group), and 20 cases were treated with traditional conservative treatment (non-surgical group). Complications during hospitalization were observed. After discharge, the patients in the two groups were followed up by telephone and outpatient clinic. The Visual Analogue Scale (VAS) score at admission, at discharge, and 3 and 6 months after discharge, and the Oswestry Disability Index (ODI) score 3 and 6 months after discharge were compared between the two groups. Results There were no statistically significant difference in age, sex, body mass index or distribution of injured vertebrae segment between the two groups (P>0.05). No serious complication occurred in any group during hospitalization. The difference in the length of hospital stay between the two groups was not statistically significant (P>0.05). The bed rest in the robot group was shorter than that in the non-surgical group [(4.83±0.92) vs. (43.05±2.70) d, P<0.05]. The VAS scores at discharge (2.50±0.51 vs. 5.05±1.00), 3 months after discharge (1.83±0.71 vs. 3.10±0.72) and 6 months after discharge (1.50±0.51 vs. 1.90±0.79) in the robot group were lower than those in the non-surgical group (P<0.05). The ODI scores 3 months after discharge (21.89±1.41 vs. 30.40±3.00) and 6 months after discharge (10.72±2.37 vs. 12.10±2.29) in the robot group were significantly lower than those in the non-surgical group (P<0.05). Conclusion For patients with TLICS 4 thoracolumbar fracture, the early clinical effect of robot-assisted surgical treatment is better than that of non-surgical treatment.
Objective To compare the surgical efficacy of different operating methods for treating old thoracolumbarfracture with spinal cord injury. Methods From September 2000 to March 2006, 34 cases of old thoracolumbar fractures with spinal cord injury were treated. Patients were divided into 2 groups randomly. Group A (n=18): anterior approach osteotomy, il iac bone graft and internal fixation were used. There were 10 males and 8 females with the age of 17-54 years. The apex level of kyphosis was T11 in 2 cases, T12 in 5 cases, L1 in 8 cases and L2 in 3 cases. The average preoperative Cobb angle of kyphosis was (36.33 ± 3.13)°, and the average preoperative difference in height between anterior and posterior of involved vertebra was (22.34 ± 11.61) mm. Neurological dysfunction JOA score was 10.44 ± 1.12. Group B (n=16): transpedicular posterior decompression and internal fixation were used. There were 8 males and 8 females with the age of 18-56 years. The apex level of kyphosis was T11 in 2 cases, T12 in 6 cases, L1 in 7 cases and L2 in 1 case. The preoperative Cobb angle of kyphosis was (38.55 ± 4.22)°, and the preoperative difference in height between anterior and posterior of involved vertebra was (20.61 ± 10.22) mm. Neurological dysfunction JOA score was 10.23 ± 2.23. Results All the patients were followed up for 9-46 months with an average of 13.5 months. Cobb angle was (12.78 ± 3.76)° in group A, which was improved by (24.23 ± 1.64)° campared to that of preoperation; and was (10.56 ± 4.23)° in group B, which was improved by (26.66 ± 1.66)°. JOA score was 14.21 ± 1.08 in group A, which wasimproved by 3.92 ± 1.33; and it was 13.14 ± 2.32 in group B, which was improved by 3.12 ± 1.95. The average postoperative difference between anterior height and posterior height of vertebral body in group A was (3.11 ± 1.06) mm, which was improved by (18.03 ± 2.14) mm; and it was (2.56 ± 1.33) mm in group B, which was corrected by (20.36 ± 3.78) mm. There were statistically significant differences in the above indexes between preoperation and postoperation in 2 groups (P lt; 0.01), but no significant differences between 2 groups (P gt; 0.05). In group A, pleural effusion occurred in 2 cases and local pulmonary collapse in 4 cases and intercostals neuralgia in 1 case. In group B, leakage of cerebrospinal fluid occurred in 3 cases. Conclusion Both anterior and posterior approach are capable of treating of the old thoracolumbar fracture with incomplete spinal cord injury and providing the satisfying result of deformation correction, neurological decompression and neurological functional recovery to a certain extent.
ObjectiveTo compare the effectiveness and screw planting accuracy of percutaneous reduction and internal fixation with robot and traditional fluoroscopy-assisted in the treatment of single-level thoracolumbar fractures without neurological symptoms.MethodsThe clinical data of 58 patients with single-level thoracolumbar fractures without neurological symptoms between December 2016 and January 2018 were retrospectively analysed. According to different surgical methods, the patients were divided into group A (28 cases underwent robot-assisted percutaneous reduction and internal fixation) and group B (30 cases underwent fluoroscopy-assisted percutaneous reduction and internal fixation). There was no neurological symptoms, other fractures or organ injuries in the two groups. There was no significant difference in general data of age, gender, fracture location, AO classification, time from injury to surgery, and preoperative vertebral anterior height ratio, sagittal Cobb angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI) score between the two groups (P>0.05). The screw placement time, operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, hospitalization time, operation cost, postoperative complications, VAS score, ODI score, anterior vertebral height ratio, and sagittal Cobb angle before operation, at 3 days, 6 months after operation, and at last follow-up were recorded and compared between the two groups. The accuracy of the pedicle screw placement was evaluated by Neo’s criteria.ResultsThe screw placement time, operation time, and intraoperative fluoroscopy frequency of group A were significantly less than those of group B, and the operation cost was significantly higher than that of group B (P<0.05). But there was no significant difference in intraoperative blood loss and hospitalization time between the two groups (P>0.05). Both groups were followed up 12-24 months, with an average of 15.2 months. The accuracy rate of screw placement in groups A and B was 93.75% (150/160) and 84.71% (144/170), respectively, and the difference was significant (χ2=5.820, P=0.008). Except for 1 case of postoperative superficial infection in group A and wound healing after dressing change, there was no complication such as neurovascular injury, screw loosening and fracture in both groups, and there was no significant difference in the incidence of complications between the two groups (χ2=0.625, P=0.547). The anterior vertebral height ratio, sagittal Cobb angle, VAS score, and ODI score of the two groups were significantly improved (P<0.05); there was no significant difference between the two groups at all time points after operation (P>0.05).ConclusionThe spinal robot and traditional fluoroscopy-assisted percutaneous reduction and internal fixation can both achieve satisfactory effectiveness in the treatment of single-level thoracolumbar fractures without neurological symptoms. However, the former has higher accuracy, fewer fluoroscopy times, shorter time of screw placement, and lower technical requirements for the operator. It has wide application potential.
Objective To discuss the effectiveness of anterolateral decompression and three column reconstruction through posterior approach for the treatment of unstable thoracolumbar fracture. Methods Between March 2009 and October 2011, 39 patients with unstable burst thoracolumbar fracture were treated. Of them, there were 32 males and 7 females, with an average age of 43.8 years (range, 25-68 years). The injury causes included falling from height in 17 cases, bruise in 10 cases, traffic accident in 4 cases, and other in 8 cases. The fracture was located at the T10 level in 1 case, T11 in 9 cases, T12 in 6 cases, L1 in 14 cases, L2 in 7 cases, L3 in 1 case, and L4 in 1 case. According to Frankel classification before operation, 5 cases were classified as grade A, 5 as grade B, 9 as grade C, 14 as grade D, and 6 as grade E. Before operation, the vertebral kyphosis Cobb angle was (26.7 ± 7.1)°; vertebral height loss was 37.5% ± 9.5%; and the space occupying of vertebral canal was 73.7% ± 11.3%. The time between injury and operation was 1-4 days (mean, 2.5 days). All patients underwent anterolateral decompression of spinal canal by posterior approach and three column reconstruction. After operation, the vertebral height restoration, correction of kyphosis, decompression of the spinal canal, and the recovery of nerve function were evaluated. Results Increase of paraplegic level, urinary infection, and pressure sore occurred in 1 case, 1 case, and 2 cases, respectively; no incision infection or neurological complications was observed in the other cases, primary healing of incision was obtained. The patients were followed up 12-36 months (mean, 27 months). The patients had no aggravation of pain of low back after operation; no loosening and breaking of screws and rods occurred; no titanium alloys electrolysis and titanium cage subsidence or breakage was observed. The imaging examination showed that complete decompression of the spinal canal, satisfactory restoration of the vertebral height, and good physiological curvature of spine at 2 years after operation. At last follow-up, 1 case was classified as Frankel grade A, 2 as grade B, 2 as grade C, 10 as grade D, and 24 as grade E, which was significantly improved when compared with preoperative one (Plt; 0.05). At immediate after operation and last follow-up, the Cobb angle was (6.3 ± 2.1)° and (6.5 ± 2.4)° respectively; the vertebral height loss was 7.9% ± 2.7% and 8.2% ± 3.0% respectively; and the indexes were significantly improved when compared with preoperative ones (P lt; 0.05). Conclusion The technique of anterolateral decompression and three column reconstruction through posterior approach is one perfect approach to treat unstable thoracolumbar fracture because of complete spinal cord canal decompression, three column reconstruction, and immediate recovery of the spinal stability after operation.
Objective To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures. Methods The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T11 in 2 cases, T12 in 5 cases, L1 in 7 cases, and L2 in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator. Results The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones (P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant (P<0.05), but the difference in AVH and PVH were not significant (P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant (P<0.05), and there was no significant difference in LKA and PVH (P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score (P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal (P<0.05). ConclusionThe Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.
Objective To explore the safety and effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation in the treatment of ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. Methods A clinical data of 20 patients with ankylosing spondylitis kyphosis combined with acute thoracolumbar spine fracture, who were treated with one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation between April 2016 and January 2022, was retrospectively analyzed. Among them, 16 cases were male and 4 cases were female; their ages ranged from 32 to 68 years, with an average of 45.9 years. The causes of injury included 10 cases of sprain, 8 cases of fall, and 2 cases of falling from height. The time from injury to operation ranged from 1 to 12 days, with an average of 7.1 days. The injured segment was T11 in 2 cases, T12 in 2 cases, L1 in 6 cases, and L2 in 10 cases. X-ray film and CT showed that the patients had characteristic imaging manifestations of ankylosing spondylitis, and the fracture lines were involved in the anterior, middle, and posterior columns and accompanied by different degrees of kyphosis and vertebral compression; and MRI showed that 12 patients had different degrees of nerve injuries. The operation time, intraoperative bleeding, intra- and post-operative complications were recorded. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were used to evaluate the low back pain and quality of life, and the American spinal cord injury association (ASIA) classification was used to evaluate the neurological function. X-ray films were taken, and local Cobb angle (LCA) and sagittal vertical axis (SVA) were measured to evaluate the correction of the kyphosis. Results All operations were successfully completed and the operation time ranged from 127 to 254 minutes (mean, 176.3 minutes). The amount of intraoperative bleeding ranged from 400 to 950 mL (mean, 722.5 mL). One case of dural sac tear occurred during operation, and no cerebrospinal fluid leakage occurred after repair, and the rest of the patients did not suffer from neurological and vascular injuries, cerebrospinal fluid leakage, and other related complications during operation. All incisions healed by first intention without infection or fat liquefaction. All patients were followed up 8-16 months (mean, 12.5 months). The VAS score, ODI, LCA, and SVA at 3 days after operation and last follow-up significantly improved when compared with those before operation (P<0.05), and the difference between 3 days after operation and last follow-up was not significant (P>0.05). The ASIA grading of neurological function at last follow-up also significantly improved when compared with that before operation (P<0.05), including 17 cases of grade E and 3 cases of grade D. At last follow-up, all bone grafts achieved bone fusion, and no complications such as loosening, breaking of internal fixation, and pseudoarthrosis occurred. Conclusion One-stage posterior eggshell osteotomy and long-segment pedicle screw fixation is an effective surgical procedure for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. It can significantly relieve patients’ clinical symptoms and to some extent, alleviate the local kyphotic deformity.
ObjectiveTo compare the effectiveness of robot-assisted (RA) minimally invasive surgery versus traditional fluoroscopy-assisted (FA) open posterior fixation surgery in treating thoracolumbar fractures with ankylosing spondylitis (AS). MethodsA clinical data of 21 cases of thoracolumbar fractures with AS who met the selection criteria between December 2016 and December 2023 was retrospectively analyzed. Ten cases underwent RA minimally invasive surgery group (RA group) and 11 cases underwent FA open posterior fixation surgery (FA group). There was no significant difference in gender, age, fracture segment distribution, fracture type, time from injury to surgery, visual analogue scale (VAS) score, and American Spinal Injury Association (ASIA) grading between RA group and FA group (P>0.05). The operation time, intraoperative blood loss, radiation exposure time, radiation dose, hospital stay, and complications of the two groups were recorded. According to Gertzbein-Robbins criteria, the accuracy of screw implantation was evaluated by CT within 1 week after surgery. During follow-up, pain and nerve function were evaluated by VAS score and ASIA grading. ResultsAll patients underwent surgery successfully, and there was no significant difference in operation time (P>0.05). The intraoperative blood loss and hospital stay in the RA group were significantly less than those in the FA group (P<0.05), and the radiation exposure time and radiation dose were significantly more than those in the FA group (P<0.05). A total of 249 pedicle screws were implanted in the two groups, including 118 in the RA group and 131 in the FA group. According to the Gertzbein-Robbins criteria, the proportion of clinically acceptable screws (grades A and B) in the RA group was significantly higher than that in the FA group (P<0.05). Patients in both groups were followed up 3-12 months, with an average of 6.8 months. The VAS scores of the two groups after surgery were significantly lower than those before surgery, and the differences were significant (P<0.05). The RA group had lower scores than the fluoroscopy group at 1 week and 3 months after surgery (P<0.05). There was no significant difference in neurological function grading between groups at 1 week and 3 months after surgery (P>0.05). In the FA group, 1 case of deep infection and 1 case of deep vein thrombosis of lower extremity occurred, while no complication occurred in the RA group, and there was no significant difference in the incidence of complications between groups (P>0.05). Conclusion Both RA minimally invasive surgery and FA open posterior fixation surgery can achieve good effectiveness. Compared with the latter, the former has more advantages in terms of intraoperative blood loss, hospital stay, and accuracy of pedicle screw insertion.
Objective To introduce a scout view scanning technique of back-forward bending CT (BFB-CT) in simulated surgical position for evaluating the remaining real angle and flexibility of thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture. Methods A total of 28 patients with thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture who met the selection criteria between June 2018 and December 2021 were included in the study. There were 6 males and 22 females with an average age of 69.5 years (range, 56-92 years). The injured vertebra were located at T10-L2, including 11 cases of single thoracic fracture, 11 cases of single lumbar fracture, and 6 cases of multiple thoracolumbar fractures. The disease duration ranged from 3 weeks to 36 months, with a median of 5 months. All patients received examinations of BFB-CT and standing lateral full-spine X-ray (SLFSX). The thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), local kyphosis of injured vertebra (LKIV), lumbar lordosis (LL), and the sagittal vertical axis (SVA) were measured. Referring to the calculation method of scoliosis flexibility, the kyphosis flexibility of thoracic, thoracolumbar, and injured vertebra were calculated respectively. The sagittal parameters measured by the two methods were compared, and the correlation of the parameters measured by the two methods was analyzed by Pearson correlation. Results Except LL (P>0.05), TK, TLK, LKIV, and SVA measured by BFB-CT were significantly lower than those measured by SLFSX (P<0.05). The flexibilities of thoracic, thoracolumbar, and injured vertebra were 34.1%±18.8%, 36.2%±13.8%, and 39.3%±18.6%, respectively. Correlation analysis showed that the sagittal parameters measured by the two methods were positively correlated (P<0.001), and the correlation coefficients of TK, TLK, LKIV, and SVA were 0.900, 0.730, 0.700, and 0.680, respectively. Conclusion Thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture shows an excellent flexibility and BFB-CT in simulated surgical position can obtain the remaining real angle which need to be corrected surgically.
Objective To evaluate the effectiveness of using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach to treat thoracolumbar kyphosis caused by old fracture. Methods Between June 2008 and June 2010, 15 cases of thoracolumbar kyphosis caused by old fracture were treated with pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach. There were 9 males and 6 females with a mean age of 54.6 years (range, 39-65 years). The disease duration was 5 months to 3 years with an average of 1.5 years. Fractured segments included T11 in 1 case, T12 in 4 cases, L1 in 5 cases, and L2 in 5 cases. Ten patients had nerve symptom, according to American Spinal Injury Association (ASIA) grading, 3 cases were classified as grade B, 4 cases as grade C, and 3 cases as grade D, of which 3 cases had sexual and sphincter dysfunction. At preoperation, the Cobb angle was (47.4 ± 10.2)°; the Oswestry disability index (ODI) score was 67.9% ± 6.9%; and the visual analogue scale (VSA) was 8.6 ± 1.4. Results The wounds obtained primary healing. The mean follow-up time was 28 months (range, 13-60 months). X-ray films showed intervertebral bone fusion was obtained within 6-11 months (mean, 10.2 months). No fixation loosening or breaking occurred during follow-up. Kyphosis was corrected, and lumbar back pain was relieved. At 1 year after operation, Cobb angle was significantly corrected to (13.3 ± 7.7)° (t=72.80, P=0.00); ODI score was significantly improved to 25.2% ± 4.6% (t=48.04, P=0.00); VAS score was significantly decreased to 2.3 ± 0.6 (t=26.52, P=0.00). According to ASIA grading in 10 patients with spinal cord injury, the spinal cord function was improved by 1 grade in 8 cases (3 cases from grade B to C, 3 cases from grade C to D, and 2 cases from grade D to E); 3 patients with sexual and sphincter dysfunction recovered in different degrees. Conclusion Using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach is an effective method to treat thoracolumbar kyphosis caused by old fracture.
Objective To investigate the effectiveness of trans-intervertebral space osteotomy (TIO) combined with cage implantation in treatment of old thoracolumbar compression fracture with kyphosis. Methods A clinical data of 59 patients with old thoracolumbar compression fracture and kyphosis, who met the selection criteria between January 2010 and August 2020, was retrospectively analyzed. Among them, 20 cases underwent TIO combined with cage implantation (group A), 21 patients underwent TIO (group B), and 18 patients underwent pedicle subtraction osteotomy (PSO; group C). There was no significant difference in gender, age, time from injury to operation, fracture segment, and preoperative Cobb angle, average height of functional spinal unit (FSU), sagittal vertical axis (SVA), visual analogue scale (VAS) score, Japanese Orthopedic Association (JOA) score, and Oswestry disability index (ODI) between groups (P>0.05). The operation time, intraoperative blood loss, and postoperative complications were recorded. Imaging review was performed to observe the fusion of the bone graft. Cobb angle, average height of FSU, and SVA were measured. VAS score, JOA score, and ODI were used to evaluate the degree of low back pain and lumbar function. Frankel grading was used to evaluate neurological function. Results The operations of 3 groups were successfully completed. The operation time and intraoperative blood loss were significantly lower in groups A and B than in group C (P<0.05); there was no significant difference between group A and group B (P>0.05). All incisions healed by first intention. Patients in all groups were followed up 23-27 months, with an average of 24.8 months. There was no significant difference in follow-up time between groups (P>0.05). At last follow-up, VAS score, JOA score, ODI, and SVA of 3 groups significantly improved when compared with those before operation (P<0.05), there was no significant difference in the differences of pre- and post-operation between groups (P>0.05). The neurological function grading of 3 groups was Frankel grade E. The Cobb angle and the average height of FSU in 3 groups at immediate and last follow-up significantly improved when compared with preoperative ones (P<0.05), there was no significant difference between immediately after operation and last follow-up (P>0.05). And there were significant differences in above indexes between groups at each time point (P<0.05). At last follow-up, the osteotomy site fused without internal fixation failure or pseudarthrosis formation were observed in 3 groups. ConclusionFor patients with old thoracolumbar compression fractures with kyphosis, the effectiveness of TIO combined with cage implantation is satisfactory. Compared with TIO and PSO, it can obtain more deformity correction degree and less invasive.